Patients With Low-Cost Insurance Struggle To Find Specialists

Dr. Charu Sawhney examines patient Mang Caan. Sawhney supports the Affordable Care Act, but has been frustrated by how difficult it is to find specialists who accept some of the plans her patients bought.

Carrie Feibel for NPR

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Originally published on July 18, 2014 12:00 pm

The Hope Clinic in southwest Houston is in the very heart of Asia Town, a part of the city where bland strip malls hide culinary treasures — Vietnamese pho, Malaysian noodles, Sichuan rabbit and bubble tea.

Inside the clinic, internist Charu Sawhney sees patients from many countries and circumstances. She's a big believer in the Affordable Care Act since most of her patients have been uninsured. She actively pushed many of them to sign up for the new plans.

But now she's seeing something she didn't expect. When patients need treatment unavailable at the clinic, it's been hard to find specialists and hospitals that accept the insurance.

"I was so consumed with just getting people to sign up," she says, "I didn't take the next step to say 'Oh, by the way, when you sign up, make sure you sign up for the right plan.' "

Understandably, a lot of her patients picked lower-cost plans, she says, "and we're running into problems with coverage in the same way we were when they were uninsured."

One of her patients is a Chinese immigrant to Houston who purchased a Blue Cross Blue Shield HMO silver plan. Soon after, he was diagnosed with stomach cancer. Sawhney found an oncologist to coordinate his treatment, but she and the oncologist ran into trouble trying to schedule chemotherapy and radiation. "The process just isn't as easy as we thought it would be," she says.

That's because the two largest hospital chains in Houston, Houston Methodist and Memorial Hermann, are not in that plan's network. Neither is Houston's premier cancer hospital, MD Anderson Cancer Center.

Those are the hospitals that the patient's oncologist, Paul Zhang, calls on the most. He says coordinating surgery or radiation usually isn't a problem, because most of his patients have insurance plans with wide networks.

"I could not find a surgeon," says Zhang. Eventually Zhang found one who took the insurance, though they'd never worked together. After the surgery, Zhang tried to set up the patient's chemotherapy and radiation at Houston Methodist. But that hospital wasn't taking the plan.

Zhang says he cannot refer patients with these narrow plans to the specialists he thinks are best, and that's a problem if the cancer is particularly complicated.

"You have limited options. So you're like a second-class citizen, you know. That's my feeling, you have this insurance and you cannot see certain doctors," he says.

Sawhney was less surprised by the barriers. Medicaid patients have similar problems finding doctors, and her uninsured patients have always struggled to find care. But she thought the Affordable Care Act would be an improvement.

Her patient with stomach cancer thought so too. He asked not to be identified because he has not shared his diagnosis with close family members.

"The (insurance) agent said that a lot of doctors will accept that insurance -- but when I got sick I found out nobody wants that kind of insurance."

The biggest irony, she added, is that even Harris Health, the county-wide public hospital system in Houston, doesn't take all the new marketplace plans. Yet Sawhney can still send uninsured patients there for cancer treatment. As people learn that some doors are closed, she worries people will decide insurance isn't worth the money.

"I don't want patients to get discouraged," she says. "I don't want patients when they have a choice again to say, 'You know what? I'm just not going to sign up because it doesn't matter if I have insurance or I don't have insurance, I still have problems getting health care.' "

Narrow networks of doctors and hospitals aren't new, but they've attracted attention with the rollout of the Affordable Care Act. Analysts point out that narrow networks are a powerful tool for insurance companies seeking to control costs – especially since they can no longer control costs by excluding sick people or adjusting premiums by gender or age.

By restricting the choices in a plan, the insurer can promise more customers for the doctors and hospitals that are included. In exchange, the insurers can get a break on what they pay those doctors and hospitals.

The industry's position is that patients have choices. Plans with access to more hospitals and specialists are available, but usually at a higher price.

Louis Adams is a spokesperson for Blue Cross Blue Shield of Texas. "Our goal was to offer an array of plan choices," he says. "We created more focused networks as a way to offer a broad range of plans with lower premium prices."

Sawhney and Zhang eventually found a place for the patient to get chemotherapy and radiation.

Despite the delays and difficulties, Sawhney still believes it's better to have insurance, and she still believes in the law. But, she says, from now on she'll tell her patients to shop more carefully, taking into account price and whether they have a chronic illness. It won't be about the cheapest plan anymore, but rather the plan that best meets their medical needs.

This story is part of a reporting partnership between NPR, Houston Public Media and Kaiser Health News.

The Obama administration calls the Affordable Care Act a victory, but the real test of the law's effectiveness is still taking place in doctors' offices. Carrie Feibel of Houston Public Media has this story about one problem. A lot of doctors and hospitals don't accept some of the less expensive plans.

CARRIE FEIBEL: The Hope clinic in southwest Houston is in the very heart of Asia town. Hidden inside bland sun-drenched strip malls, you can find Vietnamese pho, Malaysian noodles, or bubble tea.

CHARU SAWHNEY: Hi, Mrs. Kahn, good to see you.

FEIBEL: The internist at the Hope Clinic, Dr. Charu Sawhney, cares for patients who speak 14 different languages.

SAWHNEY: Did you bring your inhalers today?

UNIDENTIFIED WOMAN: (Foreign language spoken).

FEIBEL: A translator helps her check the lungs of a Burmese refugee.

UNIDENTIFIED WOMAN: (Foreign language spoken).

SAWHNEY: Can I see them?

FEIBEL: Sawhney is a big believer in the Affordable Care Act. Most of her patients are uninsured, and she actively pushed many of them to sign up for the new plans, but now she's seeing something she didn't expect.

SAWHNEY: In the beginning, I was just focusing on - you know, sign up, sign up, sign up, you are the perfect candidate. I didn't take the next step to say, oh, by the way when you sign up, make sure you sign up for the right plan.

FEIBEL: Understandably, a lot of her patients picked the lower-cost plans.

SAWHNEY: And we're running into problems with coverage in the same way we were when they were uninsured.

FEIBEL: One of her patients is a Chinese immigrant to Houston. He purchased a Blue Cross Blue Shield HMO Silver Plan, and soon after was diagnosed with stomach cancer. Sawhney found an oncologist who took the patient's insurance. He even spoke Mandarin, but Sawhney says they soon ran into trouble trying to schedule treatment.

SAWHNEY: The process just isn't as easy as we thought it would be.

FEIBEL: That's because it was tough to find Houston hospitals and doctors who took the plan. The oncologist Sawhney found is Doctor Paul Zhang. He says setting up treatment usually isn't so hard because most of his patients have insurance plans with lots of options. But in this case, Houston's premier cancer hospital, MD Anderson, wasn't part of the network.

PAUL ZHANG: I could not find a surgeon. You know, normally we pick a phone call - you my best colleagues. You know, it's just there one day - 'cause most of them are not a network, surprisingly.

FEIBEL: Zhang says he spent a long time calling around before he found a surgeon who actually took the insurance. Then he tried to set up chemotherapy and radiation at Houston Methodist, but that hospital wasn't taking the plan either.

ZHANG: You have limited options. So you are like a second-class citizen. That's my feeling. You know, you have this insurance, and you cannot see certain doctors.

FEIBEL: For her part, Sawhney was less surprised by the barriers. She says Medicaid patients have similar problems finding doctors. And of course, her uninsured patients have always struggled to find care, but Sawhney thought the Affordable Care Act would be an improvement. Her patient with stomach cancer thought so too. He asked not to be identified because he has not shared his diagnosis with close family members.

UNIDENTIFIED MAN: (Through translator) The agent said that lots of doctors will accept that insurance, but when I got sick, I find out nobody want that kind of insurance.

FEIBEL: Sawhney says the biggest irony is that even the public hospital system in Houston doesn't take all the new marketplace plans. She can still send patients there who have no insurance, but she can't refer her stomach cancer patient. She worries people will decide insurance is simply not worth the money.

SAWHNEY: I don't want patients to get discouraged. I don't want patients when they have a choice again to say, you know what? I'm just not going to sign up because it doesn't matter if I have insurance or I don't have insurance. I still have problems getting health care.

FEIBEL: Insurance companies say consumers have a choice. If they want access to more hospitals and more specialists, they can get that, but those plans cost more. Louis Adams is with Blue Cross Blue Shield of Texas.

LOUIS ADAMS: Our goal was to offer an array of plan choices. We created more focused networks as a way to offer a broad range of plans with lower premium prices, both on the exchange and the retail market in general.

FEIBEL: Sawhney and Zhang eventually found a place for the patient to get chemotherapy and radiation. Despite the delays and difficulties, Sawhney still believes it's better to have insurance, and she still believes in the law.

SAWHNEY: I want this to work. The healthcare exchanges make sense to me, but when the networks are so limiting, I'm not certain how it's going to pan out over the next couple of years I think these networks need to change for this to be a reasonable solution to our healthcare issues.

FEIBEL: Next year she'll tell her patients to shop more carefully, taking into account price and whether they have a chronic illness. It won't be about the cheapest plan anymore, but rather, the best plan. For NPR News, I'm Carrie Feibel in Houston.

CORNISH: This story is part of a reporting partnership among NPR, Houston Public Media and Kaiser Health News. Transcript provided by NPR, Copyright NPR.